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Childbirth Education Outcomes:

An Integrative Review of the Literature

Mary L. Koehn, PhD(c), ARNP, LCCE, FACCE

MARY KOEHN is a doctoral candidate at the University of Kansas Medical Center in Kansas City, Kansas. She is also an assistant professor at Wichita State University in Wich- ita, Kansas.

Abstract

The purpose of this literature review was to identify and describe recent empirical studies of childbirth education outcomes and to identify areas for further study. The search produced 63 studies; only 12 met the inclusion criteria. The literature demonstrated inconclusive evi- dence regarding the effectiveness of childbirth education. None of the studies used a theoretical framework that proposed multiple factors, as opposed to childbirth edu- cation alone, that impact the outcomes. Health-focused versus illness-focused outcomes were also addressed. Journal of Perinatal Education, 11(3), 10–19; out- comes, quality of care, evaluation, childbirth education.

Childbirth education has existed as a formal structure in this country since the 1960s and has provided prepara- tion for childbirth with a focus on ‘‘natural’’ birth. Over time, the classes have continued to evolve but the under- lying purpose remains the same: to provide prenatal preparation for pregnancy, labor, and birth. Recent liter- ature suggests that childbirth education has been histori- cally evaluated in terms of outcomes that do not necessarily demonstrate the value of such programs (Hu- menick, 2000; Sims-Jones, Graham, Crowe, Nigro, & McLean, 1998; Thassri et al., 2000). As O’Meara (1993) pointed out, a basic requirement of childbirth education evaluation is the ability to measure its contribution to health and well-being, and to generate information that will guide current methods. Therefore, the purpose of this review is to identify and describe the recent empirical studies of childbirth education outcomes and to identify the gaps that need further study.

Methods

Conceptual Framework

of existing literature rather than being limited to the categories of the IQHEOM.

According to Humenick (2000), three decades of child-

Search and Review

birth education outcomes research have been guided

by

Donabedian’s (1988/1997) model: structure, process,

and outcomes. The outcomes of childbirth education have often been reported in terms of ‘‘whether it pro-

duced less death (infant mortality), less disability

term birth), and less discomfort (labor pain)’’

(Humenick, 2000, p. 595). Humenick has recommended

outcomes research guided by the Interactive

Quality

Health Education Outcomes Model (IQHEOM), a model based on the work of Mitchell, Ferketich, and

Jennings (1998) (see Figure). This model proposes that

any educational intervention affects and is affected

by

participants and the settings or agencies. That is, no single intervention (i.e., childbirth education) will pro- duce the outcome independently. The influence of the labor care providers and their philosophy are a critical variable in how couples apply aspects of their childbirth education. These important variables have generally not been addressed in research of childbirth education out- comes. Nolan (2000) concurred that nearly all empirical studies have treated attendance at childbirth education classes as a ‘‘single, uniform intervention’’ (p. 25). The IQHEOM suggested by Humenick (2000) addresses the above variables and proposes additional health-focused outcomes beyond birth experiences (e.g., influences on self-care and health-promoting behaviors, health related quality of life, the perception of being well cared for, and symptom management), which would potentially demonstrate a strength of childbirth education. In part, this model guided this review in that, as the model sug- gests, the outcomes considered were broad and included those that were wellness oriented in scope, where they existed. However, no type of outcome literature was excluded. Thus, the analysis was based on characteristics

This review was conducted via electronic search through MEDLINE, CINAHL, PSYC INFO, and Sociological Abstracts. The search period was restricted to

  • (pre- 1995–2001 studies in English. Keywords for the search included outcomes, quality of care, evaluation, and childbirth education. The electronic search produced 54 articles. A manual search of references produced an additional nine articles. Relevance criteria of the search included the following: (a) studies using either quantitative or qualitative meth- odology, (b) studies with childbirth education classes as an intervention, (c) studies that aimed to demonstrate the effectiveness of childbirth education, and (d) studies

Methods Conceptual Framework of existing literature rather than being limited to the categories of the IQHEOM.

The influence of the labor care providers and their philosophy are a critical variable in how couples apply

Figure

Model

Interactive Quality Health Education Outcomes

This figure is based on concepts from P. Mitchell, S. Ferketich,

and B. Jennings, (1998). Quality health outcomes model. IMAGE:

aspects of their childbirth education. Journal of Nursing Scholarship, 30, 43–46. (Nichols & Humenick,

2000, p. 596.)

Childbirth Education Outcomes: An Integrative Review of the Literature

Table 1

Overview of Childbirth Education Evaluation Studies

Study

Method/Framework

Sample Characteristics & Data Collection

Outcomes/Findings

Bechelmayr

Pre-post quasi-

N 35; 3rd trimester; attended at

Anxiety.

(1995)

experimental Dick- Read, Lamaze, Bradley, and ‘‘Support Less Anxiety’’

least 4 classes; 29-40 weeks Spielberger’s State-Trait Anxiety Inventory

Significant difference

Beger &

Descriptive

N 134, ‘‘Childbirth

Educational Needs. Parents: Info regarding

Beaman

None stated

classes’’—hospital, survey, Likert-

pregnancy/fetus; nutrition; infant; Preferred lecture.

(1996)

type scale

Educators: Tour; Preferred role play

Hallgren et al.

Qualitative

N 7

Perceptions of childbirth before and after education.

(1995)

Antonovsky: Concept

‘‘Antenatal classes’’ with midwives

More positive at end of class; need more content on

of Sense of Coherence

Three interviews with each participant

parenting; did not meet the needs of all the women; Fear blocked acquisition of new knowledge

Handfield &

Descriptive

N 59

Decision-making. Classes influence pain medication

Bell (1995)

None stated

1 session early pregnancy; 4 sessions third trimester Original questionnaire

(52.5%); Breastfeeding (10.2%); Length of stay (52.5%)—but classes not helpful for this variable

Hart

Descriptive

N 119

Couples’ perceptions of labor and delivery. Mothers

(1995)

None stated

6 weeks ‘‘Childbirth Ed’’ classes Labor Delivery Evaluation Scale; Labor Agency Scale; Delivery Agency Scale

scored lower than fathers; only significant difference Labor Agency Scale

Jackson

Ex-post-facto

N 60

Birth weight; health promotion behaviors. NS

(1995)

Pender’s Health

‘‘Childbirth Ed classes’’—Unequal difference in birth weight; CB Ed group scored higher

Promotion Model

groups (16 in CB Ed; 44 no classes).

on Total score, self-actualization, Health

 

Health Promotion Lifestyle Profile responsibility, Exercise, Nutrition, Interpersonal (Pender); Birth weight support. No control for previous healthy behaviors

Johnston-

Descriptive

N 45, ‘‘Childbirth Ed classes,’’

Pain perception, Level of preparedness, Satisfaction,

Robledo

None stated

Convenience, L/D Information

Perceived control. Compared higher and lower

(1998)

Measure, Childbirth Prep Measure, L/D Evaluation Scale, Labor Agency

income women; CB prep NS, Lower income less likely to attend; Control & Satisfaction NS;

Scale Preparation not associated with outcomes

Sims-Jones et al.

Descriptive

N 291, Canada, ‘‘Early pregnancy

Change in lifestyle behavior, Feelings of confidence,

(1998)

None stated

classes,’’ Self-completed questionnaires

Interest in content area, Interest in content by partner. Some behavioral change, most no change; 75% increased confidence; Interested in all topics; Significant difference between woman and partner

Smedley

Descriptive

N 127, Australia, 9 classes

Attitudes, Course Content. More positive at end of

(1999)

None stated

(8 pre-, 1 post-), Nonrandom, Questionnaires

class (NS); 75% positive regarding labor postnatal; need more content on parenting

Spiby et al.

Exploratory/

N 121, United Kingdom, 5

Use of coping strategies, Confidence, Amount of

(1999)

Convenience

‘‘antenatal sessions,’’

Practice. 88% ‘‘sighing out’’ breathing, 51%

None stated Questionnaires, Narrative postural change, 40% relaxation, 4%–5% extremely

 

confident, 62%–76% fairly confident, 46% insufficient practice in class, 84% practiced outside of class

Stamler

Qualitative

N 7, Canada, 6- or 8-week classes,

Goals for attending, satisfaction with completing

(1998)

Knowles, adult

Semi-structured interviews

the birth process. Info/prep; Anxiety/relaxation;

education; Stamler,

Control; husband participation; Socialization; Well

enablement

prepared for normal birth; Not prepared for unexpected

Table 1

Continued

Study

Method/Framework

Sample Characteristics & Data Collection

Outcomes/Findings

Thassri et al.

Qualitative

N 214, Thailand, ‘‘Health Ed

Behavior change, Satisfaction with topics.

(2000)

Participation

Program,’’ In-depth Interviews Significant change in prenatal behaviors (preparation

Action Research

for pregnancy, breastfeeding, postpartum). Moderate to high satisfaction with topics (preparation for pregnancy, nutrition, breastfeeding, delivery), except low satisfaction with preparation for postpartum topic

congruent with the breadth of the IQHEOM. Studies were excluded from the review if a specific coping strat- egy was the intervention, as opposed to education classes

as a whole. As a result, 12 studies were

identified that

met the inclusion/exclusion criteria for review.

enced decision-making, while Stamler (1998) asked if childbirth education classes were enabling or nonenabling.

3. Perceptions related to birth. Four of the 12 studies (Hallgren, Kihlgre, Norberg, & Forslin, 1995; Hart, 1995; Johnston-Robledo, 1998; Spiby, Hen-

Critique Format derson, Slade, Escott, & Fraser, 1999) investigated

The critique format used Petersen and White’s (1989) and Ganong’s (1987) guidelines for reviewing literature. Refer to Table 1 for an overview of the studies included.

aspects of the birth experience: satisfaction with the birth experience, impact on pain perception, and implementation of coping strategies. Addition- ally, they studied perception of classes.

  • 4. Class curriculum. In two of the 12 studies (Beger &

Review of Studies Beaman, 1996; Smedley, 1999), the primary focus

was a survey of participants for their input on

Hypotheses, Objectives, and Questions what is needed in classes. In addition, Beger and

All but one of the 12 studies were nonexperimental in design; therefore, most had research questions, objec- tives/aims, or implied research questions instead of hypotheses. Five outcomes categories were identified:

  • 1. Health promotion behaviors. Three of the 12 stud- ies specified health promotion behaviors as

the

focus. Jackson (1995) addressed differences in in- fant birth weight and maternal health promotion behaviors. Sims-Jones et al. (1998) also focused on

the impact of classes to prevent low birth weight,

Beaman (1996) addressed the differences between parent and educator perceptions of needed course content and teaching/learning methods.

5.

Impact on coping. The final study, Bechelmayr (1995) specifically investigated the impact of child- birth preparation on anxiety levels of the partici- pants. This was the only study that was quasi- experimental in design.

Theoretical Frameworks

including smoking cessation, nutrition,

physical

Only five of the 12 studies identified a specific theoretical framework that guided the study. The following were used: (a) Participatory Action Research (Thassri et al.,

activity, and stress reduction. The third study, Thassri et al. (2000) hypothesized that health edu-

cation could help prevent complications. 2000), (b) Knowles’ Adult Education Model (Stamler,

  • 2. Influences on self-care. Two of the 12 studies inves- tigated the influence of childbirth education on self-care issues. Handfield and Bell (1995) investi- gated whether or not childbirth education influ-

1998), Antonovsky’s Concept Sense of Coherence (Hall- gren et. al., 1995), Pender’s Health Promotion Model (Jackson, 1995), and Education and Support equals Less Anxiety (Bechelmayr, 1995). Although it was implied

Childbirth Education Outcomes: An Integrative Review of the Literature

that childbirth education should produce an outcome, none of the studies identified any additional influencing factors on the classes or other influencing factors on the participants. Thus, although not stated, it appeared that all of these studies were guided by the traditional struc- ture, process, outcomes model (Donabedian, 1988/

1997).

pregnancy classes. The classes in the remainder of the studies were referred to as a health education program (Thassri et al., 2000), antenatal sessions (Hallgren et al., 1995; Spiby et al., 1999), and childbirth education classes (Beger & Beaman, 1996; Jackson, 1995; John- ston-Robledo, 1998). Bechelmayr (1995) was the only study that was spe- cific regarding consistency with instructor qualifications,

Samples and Settings all being LCCEs. Beger and Beaman (1996) stated that six of the seven instructors in the study were RNs and

All of the studies used convenience sampling except

for

the three qualitative studies (Hallgren et al., 1995; Stamler, 1998; Thassri et al., 2000) that used purposive sampling, appropriate for this methodology. The number

of subjects in these three qualitative studies ranged

from

7 (Hallgren et al., 1995) to 214 (Thassri et al, 2000).

Excluding these qualitative studies, the number of sub-

jects in each of the studies ranged from 1995) to 291 (Sims-Jones et al., 1998).

35 (Bechelmayr,

The IQHEOM proposes that both class settings and

class participants are influential on the education process and on outcomes; therefore, they are important to con- sider in health education evaluations. Overall, only mini-

mal descriptive information existed regarding

the

structure and content of the classes. Bechelmayr (1995) was the most descriptive, stating that the sample included couples who had attended at least four childbirth educa-

that four of these were LCCEs. Midwives taught the classes in Hallgren et al.’s (1995) study, while Smedley (1999) stated that the instructors came from ‘‘a range of backgrounds’’ (p. 19) as health professionals. The remaining studies did not clearly identify the instructors. Six of the 12 studies cited hospital-based programs as the setting for classes (Beger & Beaman, 1996; Hand- field & Bell, 1995; Hart, 1995; Jackson, 1995; Spiby, et al., 1999; Thassri et al., 2000). Johnston-Robledo (1998), Sims-Jones et al. (1998), and Stamler (1998) described community-based programs, while the re- maining studies did not state the setting for the study. In summary, the contribution that settings and samples make to program outcomes is not discernable across studies.

tion classes during the 29th–40th week of pregnancy.

Methodologies

The content of these classes was structured according to Lamaze International guidelines and all instructors of the classes were certified as Lamaze Certified Childbirth

Educators or LCCEs. Only four other studies stated

number of class sessions: (a) Hart (1995), six weeks; (b) Handfield and Bell (1995), one session early pregnancy and four sessions in the third trimester; (c) Smedley

(1999), eight sessions prenatal with one session

tal; and (d) Stamler (1998), six or eight weeks. Sims- Jones et al. (1998) described the setting only as early

Three studies used qualitative methodologies: Hallgren et al. (1995), Stamler (1998), and Thassri et al. (2000). Bechelmayr’s (1995) study, quasi-experimental in design, used a pre-test, post-test method. The remaining studies were all descriptive. A mixture of qualitative and quanti- tative studies adds richness and understanding. In this
postna- field, however, no evidence exists that, to date, their findings have been integrated to build upon each other in the development of systematic knowledge.

the

Measurement

Hart (1995) and Johnston-Robledo (1998) both used

Class settings and class participants are influential on Humenick and Bugens (1981) Labor and Delivery Eval-

the education process and on outcomes; therefore, they are important to consider in health education

uation Scale. Hart also used Humenick and Bugen’s (1981) Labor Agency Scale and Delivery Agency Scale. On the other hand, Johnston-Robledo used Hodnett and

evaluations. Simmons-Tropea’s Labor Agency Scale. Although John- ston-Robledo reported previous Cronbach’s alphas as

well as reliability estimates for this study, Hart only

reported alpha coefficients for the current study.

Bechelmayr (1995) and Jackson (1995) used Spielberg-

er’s State-Trait Anxiety Inventory and Pender’s Health

Promotion Lifestyle Profile, respectively. These research-

Findings

Overall, the findings of these 12 studies were diverse.

The findings are presented according to the categories

suggested by the research questions/objectives.

ers also provided previous reliability estimates for

each 1. Health promotion behaviors. The three studies

that investigated health promotion outcomes all

suggested a positive change in some health behav-

iors. In Jackson’s (1995) study, the women who

had attended classes scored significantly higher

than the women who had not attended classes in

the areas of self-actualization, health responsibil-

ity, exercise, nutrition, and interpersonal support.

It is important to note that, in this study, the two

groups were considerably different in size: 16

women had attended childbirth education classes

of these instruments. The remaining studies reported

researcher-developed questionnaires or interview ques-

tions. Beger and Beaman (1996) indicated that the instru-

ment’s author gave permission to use the instrument, but

the report lacked clarity as to the instrument’s

original

development. Four quantitative studies used previously

developed instruments while the remaining relied on in-

struments that had not been previously tested. Thus, no

evidence exists that tools have been developed and

widely used in the evaluation of childbirth education

outcomes.

whereas 44 women had not attended. The study

Analyses

design did not control for previous use of healthy

lifestyle behaviors. Sims-Jones et al. (1998) also

found some changes in lifestyle behavior. The par-

ticipants reported the behaviors that indicated the

greatest amount of change were communication

with partner (51.2%) and relaxation (47.4%). Ad-

ditional findings demonstrated that 75.9% felt

their confidence for labor and birth had increased

and that 91.4% would recommend the prenatal

The quantitative descriptive studies mostly relied on (a)

percentages, means, and/or standard deviations (Sims-

Jones, 1998; Smedley, 1999; Spiby et al., 1999), (b) de-

scriptive statistics indicating group differences such

as

the t-test (Bechelmayr, 1995; Beger & Beaman, 1996;

Jackson, 1995), ANOVA (Hart, 1995), chi-square

(Handfield & Bell, 1995), Wilks’ Lambda

Robledo, 1998), or (c) correlation (Johnston-Robledo,

1998). These analyses are important for the research

design; however, small studies with

convenience sam-

pling limit generalizations of the findings.

All three qualitative studies included specific quota-

tions from the participants that exemplified the themes

that had been determined. All three also addressed relia-

bility and validity issues associated with the methodol-

ogy. For example, Stamler (1998) reported, ‘‘In

addition

to the validation of data with each patient during subse-

quent interviews, rigour was addressed by the use of

  • (Johnston- classes to a friend. The third study, Thassri et al. (2000), reported a significant change in behaviors related to preparation for labor and birth, breastfeeding, and postpartum period, but not in nutritional habits. The researchers suggested that the explanation for this was the traditional beliefs and food habits of this particular population (i.e., eating meat causes difficulties in the birth process due to large babies). In summary, there is some evidence of health promotion outcomes associated with childbirth education; however, there is no

content experts for confirmation of analysis’’ (p. 942).

Thassri et al. (2000) provided considerable explanatory

information regarding the methods, including analysis

techniques, associated with Participatory Action Re-

search. Similarly, Hallgren et al. (1995) included an anal-

ysis section describing the techniques used to arrive

at

their findings. Thus, the qualitative studies reviewed

showed consistency in reporting the analysis techniques

used.

The women who had attended classes scored significantly higher in the areas of self-actualization, health responsibility, exercise, nutrition, and interpersonal support.

Childbirth Education Outcomes: An Integrative Review of the Literature

evidence that these are being studied in a system-

atic or comprehensive way across studies.

at the end of classes about the birth experience.

Finally, Spiby et al. (1999) similarly found that,

after classes, 4%–5% of the women felt extremely

confident while 62%–76% felt fairly confident.

This study also addressed how many women used

one of three coping strategies in labor: ‘‘sighing

out’’ breathing, 88%; postural change, 51%; and

relaxation, 40%. This study differed from Hall-

gren et al. in that it was conducted after the birth.

In summary, although preparing to confidently

cope with the rigors of childbirth is a primary

purpose of such classes, again one finds that the

agency tools developed to measure this purpose

were only rarely used in recent studies. Addition-

ally, the evaluation of the specific tools women

  • 2. Influences on self-care. Handfield and Bell (1995)

found that classes had minimal effect on

opinions

about breastfeeding: 10.2% of the subjects

changed their opinion because of the classes and

length of hospital stay, and 52.5% changed

their

opinion but stated that classes were not helpful in

doing so. On the other hand, 52.5% reported that

the information on pain medication had

influenced

their decisions about pain relief. Important to this

review, Handfield and Bell (1995)—consistent

with the IQHEOM—concluded that evaluation

of

childbirth education is complicated because it is

difficult for the participants or researchers to

  • sepa- found to be helpful are rarely evaluated.

rate out influences of other interactions or services.

Stamler’s qualitative study (1998) found diversity

in terms of enabling or nonenabling for birth. That

is, three women believed themselves as enabled

for the birth experience, one was ambivalent, and

three were not satisfied with the birth experience.

More specifically, the women all believed they were

prepared for a normal vaginal birth but not for

the unexpected. Thus, although there is

potential

to study many aspects of self-care as a childbirth

education outcome, there is no evidence that the

potential categories have been identified or used

in any systematic way.

  • 3. Perceptions related to birth. Studies in this cate- gory measured various outcomes and used various methods of analyses, thus once again making it difficult to compare the results. Johnston-Robledo (1998) investigated the difference between lower and higher income women and found no signifi- cant differences on perceived control, satisfaction

  • 4. Class curriculum. Smedley (1999) reported per- centages and concluded that the class participants were positive towards the classes, but more content on parenting was needed. Beger and Beaman (1996) found a significant difference between parents and educators’ priorities in terms of educa- tional topics. The parents rated information re- garding pregnancy/fetus, nutrition, and infant care the highest while the educators rated the tour as the highest priority. Thus, evidence rarely exists that, in the recent evaluation studies of childbirth education as an intervention, attention is on evalu- ating the specific content of that intervention.

  • 5. Impact on coping. Bechelmayr (1995) specifically measured anxiety as the dependent variable. The study of 35 subjects demonstrated significant dif- ferences between pre- and post-class tests of anxi- ety. There was no evidence that outcomes such as anxiety are linked to measurements of confidence.

with the birth experience, pain perception, and use

of pain medication. No significant correlation

was

found between childbirth preparation and these

outcomes. On the other hand, Hart (1995) investi-

gated differences between women and their part-

ners. The only significant difference was on

Humenick and Bugen’s (1981) Labor Agency Scale

that measured the couples’ perceptions of the first

stage of labor, with fathers having a more positive

viewpoint. Hallgren et al.’s (1995) qualitative

study found that participants were more positive

Discussion

The health care community and public have accepted

childbirth education for some time, yet the recent child-

birth education outcome literature continues to demon-

strate mixed results regarding its effectiveness. As a

group, these recent studies are so different and flawed

that they really cannot be used to draw any conclusions

about childbirth education. Not only do methodologies

differ, but also considerable diversity exists in the out-

These recent studies cannot be used to draw any

Robledo, 1998). These criteria should be more widely

recognized and used (see Table 2).

Only five studies identified a theoretical framework

conclusions about childbirth education. (Bechelmayr, 1995; Hallgren et al., 1995; Jackson, 1995;

comes that are measured. This review verifies what both

Humenick (2000) and Nolan (2000) stated in that stud-

ies have treated attendance at classes as a single interven-

tion. None of these 12 studies addressed other variables

that may impact the effectiveness of childbirth education.

Stamler, 1998; Thassri et al., 2000). The use of such

frameworks guides researchers in selection of variables

to be measured. As attention is paid to which frame-

works operate well in studying outcomes of childbirth

education, studies can become more consistent and col-

lectively can better advance knowledge about the field.

In turn, childbirth education can become increasingly

evidence-based.

Methodological issues were clearly evident. One was Finally, five studies did identify influences on health

with sampling/setting issues, including lack of informa-

tion on the timing and content of the classes as well as

behaviors or self-care. Although the reviewed studies

did not consider other factors impacting on childbirth

the instructor qualifications. Thus, implications exist for

education, it was encouraging that researchers have iden-

internal validity

(Petersen & White, 1989). tified the need to study variables other than those associ-

Furthermore, these studies were conducted in seven

ated with an illness/disease orientation.

different countries: Australia (Smedley, 1999); Canada

(Sims-Jones et al., 1998; Stamler, 1998); Thailand (Thas-

sri et al., 2000); United Kingdom (Spiby et al., 1999); and

the United States (Bechelmayr, 1995; Beger & Beaman,

1996; Hallgren et al., 1995; Handfield & Bell, 1995;

Hart, 1995; Jackson, 1995; Johnston-Robledo, 1998).

Due to differing health care systems across countries and

continents, the characteristics of class structure, instruc-

Recommendations and Implications

Findings of this review suggest important weaknesses in

the recent literature on the study of childbirth education

outcomes; thus, continued advancement of knowledge

about the field is not occurring in an effective manner.

Recommendations for future research that addresses

tors, and childbirth philosophies add to setting variabil-

these weaknesses are presented below.

ity.

A second issue is that of sampling. All of the reviewed

descriptive studies used convenience sampling and,

therefore, threaten the ability to generalize. It should

be

questioned whether or not it is ethically appropriate to

randomly assign subjects to a childbirth education class.

Furthermore, it may be difficult to locate a population

where persons are willing to participate in random as-

signments. Thus, it is important to

examine strategies

that can address this sampling issue.

Another methodological issue across these studies was

measurement. The qualitative studies did address relia-

bility issues according to appropriate qualitative research

methods (Hallgren et al., 1995; Stamler, 1998; Thassri

et al., 2000). Among the quantitative research, numerous

studies used researcher-developed questionnaires, some

of which had minimal or no pretesting for reliability and

validity. Only three studies met Peterson and

Whites

(1989) criteria of ‘‘fully adequate’’ for adequacy of mea-

sures/instruments (Hart, 1995; Jackson, 1995; Johnston-

First Recommendation

Conduct studies guided by a model that expects and

accounts for input differences in client motivation, birth

Table 2

Criteria for Adequacy of Measures/

Instruments*

Definition of ‘‘Fully Adequate’’ Rating

Measures/measurement instruments are sufficiently valid and reliable (e.g., interrater agreement, test-retest reliability):

• Standard instruments with previously reported validity and reliability

or

• New instruments with accompanying documentation of validity and reliability

* Petersen, M. D., & White, D. L. (1989). An information synthesis approach to reviewing the literature. In M. D. Petersen & D. L. White (Eds.), Health care and the elderly: An information sourcebook (pp. 557). Newbury Park, CA: Sage.

Childbirth Education Outcomes: An Integrative Review of the Literature

attendant philosophies, attitudes and practices of obstet-

rical caregivers, and other factors that influence a wom-

an’s perception of childbirth (Humenick, 2000; Nichols,

1996; Shearer, 1990). Although these variables will con-

tinue to vary widely across settings, it is critical to catego-

rize and/or level each of these variables with operational

and were published between 1960–1981. (Effect size

is a measure of treatment effectiveness based on the

statistical difference between a treatment group and a

comparison group. It is calculated across studies.) The

highest positive effect sizes that Jones found were the

following: .40 on maternal fear and anxiety, .48 on wom-

definitions so they can be compared across studies. en’s self-esteem, .39 on the mother’s relationship with

her infant, and .37 on marital relationships. These are

Second Recommendation clinically significant effect sizes. The positive effect size

Conduct studies that include health-focused outcomes,

as called for in the IQHEOM, as opposed to being limited

to illness-focused outcomes (Humenick, 2000; Nich-

ols & Gennaro, 2000). This is important because,

in

former decades of research, birth satisfaction and percep-

tion in control or mastery were frequently found to be

associated with medical measures was .30. Generally,

much of childbirth education research has been un-

funded; thus, small studies predominate. A meta-analysis

of studies in the last 20 years is needed so that future

knowledge from research can be built upon facts learned

from past studies.

an outcome of childbirth education evaluation studies

(Gennaro, 1988). Yet, in the absence of biological advan-

Implications

tages, the outcomes of satisfaction and mastery have not

always been valued as important variables in and of

Using studies such as those described above may demon-

strate the current value of childbirth education and, thus,

themselves. elevate the professional status of childbirth educators

In former decades of research, birth satisfaction and

(Zwelling, 1996). Furthermore, such studies will help

provide research-based direction for future childbirth

education. An updated review is an important area: As

perception in control or mastery were

frequently today are different from those of parents in the past’’

(1996, p. 428).

Zwelling pointed out ‘‘the goals of expectant parents

found to be an outcome of childbirth education

evaluation studies.

Finally, research in this area has implications for

health services research in general. It is an opportunity

to test a model that accounts for influences on the pro-

cess, as well as to test outcomes that are health- and

Third Recommendation wellness-focused. If the goal of childbirth education is

Conduct studies that operationally define the measures

of health-focused outcomes and the continued develop-

ment and use of tools that measure these outcomes.

Fourth Recommendation

Establish standardization/categorization of the interven-

tion of childbirth education. Variations will always ap-

pear in education and content. It is important to our

knowledge development in the field to have an opera-

tionally defined set of terms for defining variables.

Fifth Recommendation

Jones (1983) conducted a statistical meta-analysis of 58

studies that examined the effects of childbirth education

health, then this is an important area of research for

promoting not only the value of childbirth education but

also that of childbirth educators as health professionals.

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Meaningful Tasks

Our love and passion for something makes other people feel love and passion for it. It takes one person who’s

awake to the possibilities, and everyone they touch will awaken to those possibilities.

Jane Hirshfield

Author of Women in Praise of the Sacred

Too much time cannot be spent in a task that is to endure for centuries.

Augustus Saint-Gaudens